TOPIC:

Hello again!

I'm not sure if this is the right place to post this. If it isn't, please forgive me, but I think this could be of our interested and I'm curious to know what do you guys and girls think about this.

Many of us take Proton Pump Inhibitors for stomach issues, like omeprazole, pantoprazole esoprazole etc... And browsing the web trying to buy some Nexium for my acid reflux and trying to find out how toxic it was to the liver, I've found this: www.hepmag.com/article/proton-pump-inhib...-liver-disease-hep-c

According to the article, patients with hepatitis C can progress to compensated cirrhosis, uncompensated cirrhosis and liver cancer because of this kind of medication.

I know it's only one study but I don't wanna take any chances. What do you guys think?

Hi John,

Here is the original article (abstract): onlinelibrary.wiley.com/doi/abs/10.1111/apt.14391

And here is an editorial talking about it: onlinelibrary.wiley.com/doi/full/10.1111/apt.14431

So if you read this:

Background: Proton pump inhibitors are among the most commonly prescribed medications in the United States. Their safety in cirrhosis has recently been questioned, but their overall effect on disease progression in noncirrhotic patients with chronic liver disease remains unclear. Aim: To determine the impact of proton pump inhibitors on the progression of liver disease in noncirrhotic patients with hepatitis C virus (HCV) infection. Methods: Using the electronically retrieved cohort of HCV-infected veterans (ERCHIVES) database, we identified all subjects who received HCV treatment and all incident cases of cirrhosis, hepatic decompensation and hepatocellular carcinoma. Proton pump inhibitor use was measured using cumulative defined daily dose. Multivariate Cox regression analysis was performed after adjusting univariate predictors of cirrhosis and various indications for proton pump inhibitor use. Results: Among 11 526 eligible individuals, we found that exposure to proton pump inhibitors was independently associated with an increased risk of developing cirrhosis (hazard ratio: 1.32; 95% confidence interval: 1.17-1.49). This association remained robust to sensitivity analysis in which only patients who achieved sustained virologic response were analysed as well as analysis excluding those with alcohol abuse/dependence. Proton pump inhibitor exposure was also independently associated with an increased risk of hepatic decompensation (HR: 3.79; 95% confidence interval: 2.58-5.57) and hepatocellular carcinoma (HR: 2.01; 95% confidence interval: 1.50-2.70). Conclusions: In patients with chronic HCV infection, increasing proton pump inhibitor use is associated with a dose-dependent risk of progression of chronic liver disease to cirrhosis, as well as an increased risk of hepatic decompensation and hepatocellular carcinoma.

Then you'd be correct that there appears to be a risk but it needs to be taken in context. With the cirrhosis risk of 1.32 we have a 95% confidence interval of 1.17 to 1.49 which means we think there is a 17% to 49% increase in cirrhosis risk (and are 95% sure it's in that range). So that's an increase in cirrhosis risk, but the biggest risk for cirrhosis in HCV is HCV so if you get SVR then your general risk profile changes like this:





So SVR delivers 1/3 the rate of mortality, 1/5 the rate of HCC and 1/10 the rate of HCC.

It looks like PPIs may compromise that improvement slightly. From memory, your 2 major issues were the HCV (now cured) and being overweight (substantially increasing the probability of fatty liver) and which you're working on. These are the big ticket health issues, and your reflux would almost certainly be improved by weight loss allowing you to use less PPIs.

So, in terms of long term health look after the big ticket items first.

1. Get rid of diseases like HCV and try to be in the healthy weight range
2. Get your blood pressure, cholesterol and blood sugar checked and fix if needs be
3. Don't smoke or drink too much alcohol
4. Do exercise, eat good food, drink water and get enough sleep

Once you have the basics to hand look at the smaller issues like PPIs. There is no such thing as a drug that does not have side effects and you don't get any issues with drugs you're not taking. This advice also applies to supplements, most of which have been shown to have no long term benefits and some long term issues.

Thanks again Dr. James for this awesome reply and the links.

Reading your reply and the editorial, I've realized that I've missed something important. PPI may affect the course of the virus and create issues, but for that to happen, you've got to have the virus which is not my case anymore, thankfully.

The main reason I've brought this study, besides my anxiety, is to warn people about in treatment the side effects of PPI.

I know it's silly of me, because I couldn't even read the study properly, but I wasn't take PPIs in my first consultation with my doctor and I had a really minor case of reflux. She encouraged me to use PPI. If I had this information, in my specific case, I would have opted to not use it.

Also, after reading your reply, I've realized that I can certainly use more context in my life. I tend to worry too much about the small things and don't see the obvious ones.

My blood pressure and cholesterol are fine thankfully. The only issue is that during treatment my insulin got to a pre-diabetic level even with the fact that I was losing weight. I've read that the virus is closely tied to diabetes, I just hope that getting rid of the virus didn't open some sort of metabolic pandora's box. I know that this is weight related, but my glucose was always stable around 94 and my glycated hemoglobin was normal at 5.3 and suddenly got to 108 in a few months. That never happened before. That was 108 result was almost six months ago, so I’m worried that the next test might come back diabetic. If it goes from 94 to 108 in a couple months who knows what 6 months can do.

I'm going back to my doctor and I'm gonna ask her another glucose test. When I've get the results I'm gonna to make that appointment with you that we've discussed a couple posts ago. I didn't schedule earlier because I still don't have the results.

Thanks again for your kindness.